Higher heights: a greater ambition for maternal and child nutrition in South Asia

Research Summary ¹

Poor nutrition in early life threatens the growth and development of children, which has a knock-on effect on the sustainable development of nations. This is particularly so in South Asia, where 40% of the world’s stunted children (59 million children) and 53% of the world’s wasted children (27 million children) live (UNICEF et al, 2018). Although the prevalence of child stunting is falling in the region, the pace of progress is too slow and most countries with available data are not on track to meet stunting reduction targets. The UNICEF Regional Office for South Asia commissioned a series of papers in 2016-2017 to fill knowledge gaps in the current body of evidence on stunting drivers, who is most affected and effective programme approaches. This overview paper summarises the evidence from these analyses and examines the implications for the direction of future advocacy, policy and programme actions. 

Child growth and development 

Analysis of pooled national survey data from Bangladesh, India, Nepal and Pakistan shows that stunted is concentrated among children of households experiencing multiple forms of deprivation, including poor child diets, low levels of maternal education and household poverty (Kirshna et al, 2018). Large inter?country differences were found in average rates of stunting reduction, from 0.6 percentage points (pp) per year in Pakistan, 1.3 pp in India, 2.9 pp in Bangladesh and 4.1 pp in Nepal. Stunting has declined across all wealth quintiles in all countries, but inequalities among wealth quintiles have persisted and widened in Nepal and Pakistan. 

A retrospective case series analysis (Aguyao et al, 2018) examining the effectiveness of Pakistan’s community-based management of acute malnutrition (CMAM) programme for severely wasted children (most of whom were aged 6-23 months) found that the programme was effective in achieving high survival (99.6%) and recovery (87.8%) rates. Severely wasted or stunted children had higher death and lower recovery rates compared to other children, suggesting that targeting children age 6-23 months old with multiple anthropometric failure will increase impact. 

As child survival improves in South Asia, the developmental consequences of poor nutrition in early life become a more pressing concern than mortality, particularly given the high number of children with low cognitive and socio-emotional test scores in the region (McCoy et al, 2016). Pooled data from multiple indicator cluster surveys (MICS) in Bangladesh, Bhutan, Nepal and Pakistan found that stunted children were at increased risk of sub-optimal learning/cognition development at three to four years old, but found no association between wasting and learning/cognition development (Kang et al, 2018), suggesting that interventions effective in improving linear growth in the first years of life may improve early childhood development. 

Childhood anaemia is also associated with impaired cognitive development and possibly motor development. Studies from Nepal and Pakistan (Harding et al, 2018) and Bhutan (Campbell et al, 2018) show that anaemia is more likely in children with an anaemic mother and in infants (suggesting that mother’s anaemia status may affect that of her child), in stunted children in all three countries and children with thin mothers in Pakistan (reflecting the contribution of dietary inadequacy before and during pregnancy and in childhood). 

Maternal nutrition and low birth weight (LBW)

South Asia has the highest prevalence of LBW (26%) in the world (Lee et al, 2013), reflecting the poor status of women’s nutrition in the region. Goudet et al (2018) estimate that one in 10 South Asian women of reproductive age have low stature (<145 cm), one in five have low body mass index (BMI) (<18.5 kg/m2) and overweight is rising rapidly, all of which are risk factors for child stunting. Pooled national survey data from six South Asian countries (Harding et al, 2018) show that children with reported LBW are significantly more likely to be wasted and severely wasted than non?LBW children and LBW is a predictor of concurrent wasting and stunting. Anaemia in women of reproductive age in Nepal and Pakistan is associated with thinness (BMI <18.5 kg/m2) and children under five years old are more likely to be anaemic if their mother is anaemic. This and the Campbell et al (2018) study in Bhutan show that anaemia is concentrated in the most disadvantaged women, including those from the poorest households in Pakistan, women without schooling in Bhutan, and women lacking sanitation facilities in Bhutan and Nepal. The prevalence of anaemia in pregnant women in Bhutan is lower than non?pregnant, an atypical finding suggesting that iron folic acid (IFA) supplementation during antenatal care is effectively protecting pregnant women from anaemia.

A combination of nutrition-specific and nutrition-sensitive actions are needed to address women’s low-quality diets, poor access to health, and nutrition services and their causes. A systematic review by Goudet et al (2018) identifies barriers to pregnant women receiving and consuming IFA and calcium supplements at maternal-level (low women’s education level and knowledge), household-level (low husband’s education level, support from husband and household wealth) and health-facility level (late timing of first antenatal visit and low number of visits). Programme delivery platforms reaching pregnant women with supplements in their homes and communities, combined with information and counselling, can improve access to services and consumption of supplements. 

Breastfeeding

Using pooled data from six South Asian countries, Harding et al (2018) find that children were less likely to be wasted if they were breastfed within the first hour of birth, were not given any pre-lacteal foods, and were exclusively breastfed. The rapid fall in the prevalence of wasting during the first few months of life in several South Asian countries suggests that early and exclusive breastfeeding may help infants recover from LBW. Focusing on Bhutan, Campbell et al (2018b) report that children under two years old are less likely to be overweight if they are currently breastfed. 

Benedict et al (2018a) identify a steady increase in early initiation of breastfeeding, avoidance of pre-lacteal feeding and exclusive breastfeeding in Bangladesh, India and Nepal over the last 25 years. Despite this, only about half of children in these countries benefit from early initiation of breastfeeding and exclusive breastfeeding, and rates of continued breastfeeding at two years have remained stagnant at ~70%. Progress in Afghanistan and Pakistan has lagged behind other countries, with recent declines in breastfeeding practices in Afghanistan and in the early initiation of breastfeeding and avoidance of pre-lacteal feeding in Pakistan.

Using data from national surveys, Nguyen et al (2018) report that socio?economic inequalities in the early initiation of breastfeeding and exclusive breastfeeding in India narrowed between 2006 and 2016, a significant achievement given the rising economic equalities in the country. Improvements in breastfeeding in lower socioeconomic quintiles appear to have been driven by improved access to and use of health and nutrition services by mothers and children.

Multivariate analysis of national survey datasets from South Asia’s five largest countries (Benedict et al 2018a and 2018b) reveals that common predictors of delayed initiation of breastfeeding, pre-lacteal feeding and not being exclusively breastfed include infant being born by caesarean section, small size at birth and home delivery (suggesting that these women and infants need more breastfeeding support) and low women’s empowerment. A review of 31 studies by Benedict et al (2018b) reports that programmes to support breastfeeding are more likely to be effective if they include multiple interventions (education and counselling, community mobilisation, mass media and newborn health initiatives) in multiple intervention environments (home, community and health facility). Other important factors appear to be intervention coverage, timing relative to the age of the child, frequency, duration and targeting.

Complementary foods and feeding practices 

Poor complementary feeding practices are highly prevalent in South Asia (UNICEF, 2016) and often predict stunting and wasting in the first two years of life. The likelihood of stunting is higher in South Asia in infants aged 6-8 months who are not fed any complementary foods and in children aged 6-23 months whose diets do not meet minimum dietary diversity (MDD) (Kim et al, 2017). Likelihood of wasting in children age 6-23 months is higher if their diets do not meet MDD and of severe wasting if their diets do not meet minimum meal frequency (MMF) (Harding, Aguayo, and Webb, 2018).  In India, not meeting MDD is also associated with concurrent wasting and stunting. 

A review of South Asia national survey data (2006-2013) found that only 57% of infants aged 6-8 months are fed any complementary foods and, of the diets of children aged 6-23 months, only 48% meet MMF, 33% meet MDD and 21% meet minimum adequacy (sufficient number of meals, food groups, and breastmilk or milk feeds) (Aguayo, 2017). Across all countries, MDD is consistently lower than MMF, indicating that MDD is a greater problem. Considerable variation in feeding practices exists between countries and only Sri Lanka and the Maldives have rates that exceed 50% for all these practices. 

Three multivariate analyses of national survey data in Afghanistan, Bangladesh and Nepal (Na et al 2018a, 2018b and 2018c) show that complementary feeding practices are more likely to be sub-optimal among infants (6-11 months), first-born children, children whose mothers are younger or less educated, and in communities with poor access to health and nutrition services. Cultural beliefs continue to be a barrier to recommended feeding practices in Nepal, where the Dalit and minority ethnic and religious castes have poorer complementary feeding practices than other population groups. Wealth quintile is associated with dietary diversity (DD) in Afghanistan, Bangladesh and Bhutan, suggesting availability of affordable nutritious foods is a common barrier to diverse diets in South Asia (Cambell et al, 2018b). Nguyen et al (2018) show that the equity gaps in complementary feeding practices between socio?economic status quintiles in India narrowed between 2006 and 2016, but practices remain poor across all groups. Paintal and Aguayo (2016) show that harmful feeding practices during childhood illness are a widespread concern in South Asia, in part driven by inadequate and sometimes harmful advice from health workers. Information, education and counselling delivered by a range of well?trained primary healthcare workers and community resource persons can improve the timeliness, frequency, diversity and/or adequacy of complementary feeding, although impact may be limited by lack of availability or affordability of nutritious foods (Aguayo, 2017). 

Implications for future advocacy, policy and programme actions 

1. The concurrence of child stunting with wasting and anaemia in South Asia requires governments to address all forms of malnutrition in an integrated manner across the life cycle. 

In the past there has been a tendency to address different forms of malnutrition in isolation and with varying levels of intensity. However, they often affect the same children and share common risk factors (Khara & Dolan, 2014). Policies and programmes should move away from siloed approaches and realign to address child malnutrition in all its forms. 

2.  Improving women’s and children’s diets is central to breaking the inter-generational    cycle of malnutrition in South Asia.

Complementary foods and feeding practices in South Asia remain unacceptably poor due to weaker policy on complementary feeding compared to breastfeeding and a lack of clarity in interventions, approaches and coordination between sectors on this issue. Children’s diets need much greater attention by all stakeholders concerned and strategies are needed to improve access to nutritious and affordable foods, coupled with communication interventions for behaviour and social change. This series reaffirms the close connection between the nutritional status of a mother and her children and the need to tackle dietary drivers of poor women’s nutrition before and during pregnancy. 

3. A coordinated, multi-system approach is needed to ensure families have all the inputs they need for children’s healthy growth. 

Coordination between the food, health, social protection, water, sanitation and hygiene (WASH) and education systems is needed and between different levels of government to combine actions to improve the nutrition status of women and young children. 

4. Deliberate actions are needed to address the disparities and inequalities in child growth and early life. 

Targeted efforts are needed to reach children, mothers and communities at greatest risk of malnutrition. Interventions should focus on children born small; children under two years of age; younger, less experienced mothers; and poorer households. At community level the focus should be on communities with higher levels of anthropometric failure and lower access to maternal and child health and nutrition services, using trained healthcare workers and community volunteers. 

5. Continued attention is needed in all countries to gather, analyse and use data to assess progress and inform decisions.

This includes the use of routine information systems and periodic surveys to gather data on anthropometric indicators, feeding practices and service coverage. Studies and implementation research are also needed to better understand the context-specific barriers, enablers and pathways to improving access to services and adoption of recommended nutrition behaviours and practices.  

Conclusions 

The South Asia region bears a disproportionate burden of stunted children who experience worse health, cognition and learning outcomes. These children are concentrated in the most economically disadvantaged households and often experience multiple concurrent forms of nutrition deprivation. More attention is needed to improve the nutritional status of women before and during pregnancy and the diets of infant and young children in the first two years of life, while addressing underlying drivers. A coordinated, multi-system approach and actions to tackle inequalities are needed. 

Endnote

¹Torlesse H, Aguayo VM. Aiming higher for maternal and child nutrition in South Asia. MaternChild Nutr. 2018;14(S4):e12739. https://doi.org/10.1111/mcn.12739 within: Hall Moran V and Pérez-Escamilla R (eds) and Aguayo VM and Torlesse H (guest eds). Higher heights: a greater ambition for maternal and child nutrition in South Asia. Maternal and Child Nutrition, November 2018, Volume 14, Supplement 4.

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